More Vigilant Monitoring For Seizures Among ICU Patients Encouraged

Main Category: Neurology / Neuroscience
Also Included In: Epilepsy;  Stroke
Article Date: 18 Jun 2009 - 3:00 PDT

email to a friend   printer friendly   view / write opinions   rate article

Two new studies published by neurologists at Columbia University Medical Center and NewYork-Presbyterian Hospital demonstrate a need for more vigilant monitoring for seizure activity among intensive care patients who may be experiencing subtle seizures that are typically unrecognized. These subtle seizures may be affecting patients' prognoses and causing long-term brain damage, death and severe disability.

Published in recent issues of the Annals of Neurology and Critical Care Medicine, both studies were led by Lawrence J. Hirsch, M.D., associate clinical professor of neurology, Columbia University Medical Center, and director of the Continuous EEG Monitoring Program at the Comprehensive Epilepsy Center at NewYork-Presbyterian Hospital/Columbia. His group, in conjunction with Drs. Stephan Mayer and Jan Claassen of the Neurological Intensive Care Unit (NICU) at NewYork-Presbyterian Hospital/Columbia, has previously shown that unrecognized seizures are common in the critically ill, particularly in those with acute brain injury, and that these seizures are associated with unfavorable outcomes. NewYork-Presbyterian/Columbia's Continuous EEG Monitoring Program is one of the largest and most academically productive in the world.

The two studies found that electroencephalography was effective in detecting subtle seizures that are often impossible to detect by visual observation. Findings demonstrated the value of continuous EEG (where electrodes are placed on the scalp a noninvasive procedure used in nonsurgical ICUs) and intracranial EEG (ICE), an invasive technology where a probe is placed in the cortex of the patient's brain. ICE is mainly used in Neurological ICUs for serious acute brain injuries, such as subarachnoid hemorrhage, severe head trauma and very large strokes (hemorrhagic or ischemic), which require other invasive brain monitoring devices.

"Monitoring for seizure activity in intensive care patients is important in order to identify small, clinically invisible seizures, which might explain why patients are not waking up namely, because they are having lots of mini-seizures in multiple locations. Treating these clinically silent seizures may lead to improved alertness, reverse ongoing brain dysfunction, and prevent progressive injury to brain cells," says Dr. Hirsch. "Intracortical electroencephalography (ICE) appears to be the preferred method to monitor seizure activity in patients requiring other invasive brain monitoring (standard in the NewYork-Presbyterian/Columbia Neurological ICU in many patients), as it provides better, real-time brain monitoring, while patients in the Medical ICU should receive continuous EEG monitoring with standard, noninvasive electrodes."

The Annals of Neurology paper, "Intracortical Electroencephalography in Acute Brain Injury," compares the use of standard scalp EEG monitoring in NICU patients with ICE monitoring. ICE was found to detect small seizures occurring within the patient's brain that the continuous EEG could not detect. ICE was also helpful in detecting ischemia (inadequate blood flow) and bleeding as soon as they occurred, and prior to detection by clinical exam or other monitoring methods. Dr. Allen Waziri, NewYork-Presbyterian/Columbia, was the first author.

The Critical Care Medicine paper, "Continuous Electroencephalography in the Medical Intensive Care Unit," examines continuous EEG monitoring in the Medical ICU (MICU) in patients with no known primary brain abnormality. Using continuous EEG monitoring, Dr. Hirsch and his research team found that seizures, and nearly continuous "spikes" that are related to seizures, were common among patients in the MICU, especially patients with sepsis (a serious systemic infection). The majority of seizures were non-convulsive, meaning that they were not visible to an observer and could only be detected by continuous EEG. These abnormal brain wave patterns were strongly associated with death and severe disability. This may help explain the enigmatic condition of sepsis-associated encephalopathy, in which patients with systemic infections become delirious or stuporous. Dr. Mauro Oddo, a medical intensivist visiting from Switzerland, was first author on the study.

"Treating certain ICU patients with anti-seizure medications might help prevent neuronal damage, reduce length of stay in the ICU and help patients wake-up sooner," says Dr. Hirsch. "Additional research is needed to determine the exact prevalence and impact of seizures and related EEG patterns on patient outcome, particularly in patients with sepsis, and to evaluate whether their prevention will improve outcomes. We are beginning some of these studies now."

Dr. Hirsch is also principal investigator of the Continuous EEG Monitoring Consortium of North America, and co-author of the "Atlas of EEG in Critical Care" (Wiley, Dec. 21, 2009).

NewYork-Presbyterian Hospital, based in New York City, is the nation's largest not-for-profit, non-sectarian hospital, with 2,242 beds. The Hospital has nearly 2 million inpatient and outpatient visits in a year, including more than 230,000 visits to its emergency departments more than any other area hospital. NewYork-Presbyterian provides state-of-the-art inpatient, ambulatory and preventive care in all areas of medicine at five major centers: NewYork-Presbyterian Hospital/Weill Cornell Medical Center, NewYork-Presbyterian Hospital/Columbia University Medical Center, NewYork-Presbyterian Morgan Stanley Children's Hospital, NewYork-Presbyterian Hospital/The Allen Pavilion and NewYork-Presbyterian Hospital/Westchester Division. One of the largest and most comprehensive health care institutions in the world, the Hospital is committed to excellence in patient care, research, education and community service. NewYork-Presbyterian is the #1 hospital in the New York metropolitan area and is consistently ranked among the best academic medical institutions in the nation, according to U.S.News & World Report. The Hospital has academic affiliations with two of the nation's leading medical colleges: Weill Cornell Medical College and Columbia University College of Physicians and Surgeons.

Columbia University Medical Center provides international leadership in basic, pre-clinical and clinical research, in medical and health sciences education, and in patient care. The medical center trains future leaders and includes the dedicated work of many physicians, scientists, public health professionals, dentists, and nurses at the College of Physicians & Surgeons, the Mailman School of Public Health, the College of Dental Medicine, the School of Nursing, the biomedical departments of the Graduate School of Arts and Sciences, and allied research centers and institutions. Established in 1767, Columbia's College of Physicians & Surgeons was the first institution in the country to grant the M.D. degree. Among the most selective medical schools in the country, the school is home to the largest medical research enterprise in New York State and one of the largest in the country.

Source: Columbia University Medical Center